A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?
Request that the provider prescribe a stool softener.
Add fluid and fiber to the diet.
Promote active range-of-motion activities.
Avoid gas-producing foods.
The Correct Answer is B
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Tachycardia is not an adverse effect of oxygen therapy. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Tachycardia can be caused by various factors, such as fever, infection, pain, or anxiety. Tachycardia can also be a sign of hypoxemia, which is a low level of oxygen in the blood, and may indicate the need for oxygen therapy.
Choice B reason: Cracks in oral mucous membranes are an adverse effect of oxygen therapy. Cracks in oral mucous membranes are a sign of dryness and irritation caused by the oxygen flow. Oxygen therapy can reduce the natural moisture and lubrication of the mouth and nose, leading to discomfort and increased risk of infection. To prevent or treat this problem, the nurse should provide the client with humidified oxygen, oral care, and hydration.
Choice C reason: Excessive pulmonary secretions are not an adverse effect of oxygen therapy. Excessive pulmonary secretions are a sign of inflammation and infection in the lungs, which can impair gas exchange and cause coughing, wheezing, and dyspnea. Excessive pulmonary secretions can be a symptom of pneumonia, which is a common cause of respiratory failure and may require oxygen therapy.
Choice D reason: Poor skin turgor is not an adverse effect of oxygen therapy. Poor skin turgor is a sign of dehydration, which is a loss of fluid from the body. Dehydration can be caused by various factors, such as vomiting, diarrhea, fever, or inadequate intake. Dehydration can affect the blood volume and pressure, and may worsen the oxygen delivery to the tissues. To prevent or treat this problem, the nurse should monitor the client's fluid balance and provide adequate hydration.
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
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